Form CMS-10394 Application for Qualified Entity Certification

APPENDIX B: paper-based QE Application Form

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1144. The time required to complete this information collection is estimated to average 500 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Date Application Submitted

Date Application Received by CMS

Section 1: General Information

Instructions: Please input the prospective applicant’s information. The listed trade name and type of applicant should be for the lead applicant. Subcontractors or partners for this effort should be listed in the Member Organizations field.

Applicant’s Trade Name/DBA
T ype of Applicant Profit Organization Non-Profit Organization Other (describe)
Applicant’s Employer ID Number
Name(s) of Contractor(s) or Member Organization(s) (Contact [email protected] to obtain further instructions to submit required contractor or member organization information)
Data Recipient’s Name

D ata Requested Regional (specify States) National

Section 2: Mailing Address

Instructions: The mailing address should be an address where mail correspondence about the application or program can be delivered.

Street Mailing Address __________________________________________________________

Suite/Mail Stop ________________________________________________________________

City _____________________________________ State ____________ ZIP Code ___________

Phone _______________________________________ Fax _____________________________

Website ______________________________________________________________________

Section 3: Contact Information

Chief Executive Officer (or other equivalent executive)

Instructions: Please provide the contact information for the CEO, or equivalent executive, who has the authority to oversee the entity’s application and QECP responsibilities.

Prefix _______

First Name____________________________________________________________________

Middle Initial ______

Last Name____________________________________________________________________

Degree ____________________

E-mail Address _________________________________________________________________

Street Mailing Address ___________________________________________________________

Suite/Mail Stop ________________________________________________________________

City _____________________________________ State ____________ ZIP Code ___________

Phone _______________________________________ Fax _____________________________

Point of Contact for Application

Instructions: Please provide the contact information for the individual who will be the primary contact for day-to-day application and program correspondence.

Prefix _______

First Name____________________________________________________________________

Middle Initial ______

Last Name____________________________________________________________________

Degree ____________________

E-mail Address _________________________________________________________________

Street Mailing Address ___________________________________________________________

Suite/Mail Stop _________________________________________________________________

City _____________________________________ State ____________ ZIP Code ___________

Phone _______________________________________ Fax _____________________________

Section 4: Standards

Instructions: Please indicate whether the entity is capable of supplying information with regard to each element by checking the appropriate box (Yes, No, N/A). Using plain language, please provide explanations in the “explanation of self-assessment” comment box.

Entities are also required to submit supporting documentation to support their self-assessment and for the purposes of the minimum requirements review and assessment. Please list the name of the supporting document, its relevance to the element, and the pages within the document that prove such relevance. Additional supporting documentation may be listed in Section 6 of this application form. Refer to the accompanying QECP Operations Manual for complete program information.

Standard 1: applicant profile

Intent: A prospective QE must provide information about its organization and structure, the types of providers and suppliers it intends to evaluate, the geographic areas for which it intends to report data, and its ability to meet financial requirements of the program.

Element 1A: Define applicant organization
Assessment:	Self -assessment:
Applicant is a legally recognized “lead” entity, accountable to CMS for the receipt of Medicare data, with clear contractual relationships identified and documented between entities (when applicable) that make it possible for the applicant to meet the QECP standards.	Yes No
Explanation of Self-assessment:
Evidence:
The applicant’s incorporation, type of organization, and licensure, if applicable. Contractors or member organizations working with the lead entity in support of their QECP activities must also include incorporation, type of organization, and licensure information as well as evidence of a contractual relationship between the lead and other entities that includes breach of contract liability with potential for collecting damages for failure to perform.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
Element 1B: Identify the geographic areas that applicant’s reports will cover
Assessment:	Self -assessment:
Applicant defines the geographic area in which performance reporting will incorporate the Medicare data.	Yes No
Explanation of Self-assessment:
Evidence:
Description of geographic area(s) by state for which the applicant requests Medicare data. If a 5% national sample is requested, a justification for the request must be included.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
Description of geographic area(s) by state for which the applicant has claims data from another payer source(s).
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Element 1C: Identify the types of providers or suppliers whose performance the applicant intends to assess using Medicare data
Assessment:	Self -assessment:
Applicant lists the types of providers and suppliers for which it intends to evaluate performance using Medicare and other claims data.	Yes No
Explanation of Self-assessment:
Evidence:
List of types of providers and suppliers to be covered in each geographic area report that uses Medicare data. The types of providers and suppliers must be those that submit claims, and are paid, for Medicare-covered services and those for which the applicant has at least one additional source of claims data. The following is a list of possible provider types as defined by the Social Security Act: Physicians Other health care practitioners Hospitals Critical access hospitals Skilled nursing facilities Comprehensive outpatient rehabilitation facilities Home health agencies Hospice programs Other facilities or entities that furnish items or services
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Element 1D: Show ability to cover the costs of performing the required functions of a qualified entity
Assessment:	Self -assessment:
Applicant’s business model is projected to cover the cost of public reporting, both the cost of the data and the cost of developing the reports.	Yes No
Explanation of Self-assessment:
Evidence:
Documentation of a program budget reviewed and, approved, and signed by the applicant’s senior executives. Evidence must come from the applicant, not from a member organization or contractor.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Standard 2: Data Sources

Intent: A prospective QE must provide evidence of the ability to combine claims data from other sources to calculate performance reports.

Element 2A: Obtain claims data from at least one other payer source to combine with Medicare Parts A and B claims data, and Part D drug event data
Assessment:	Self -assessment:
For the geographic areas identified in Element 1B and for providers and suppliers identified in Element 1C, applicant possesses claims data from at least one other source; however, obtaining claims data from two or more sources is preferable.	Yes No N/A
If the applicant does not possess other claims data at the time of application, see the QECP 2012 Operations Manual Section 2.2 and Appendix C for instructions on how to apply for a qualified-conditional certification.
Explanation of Self-assessment:
Evidence:
An attestation from the entities from which the applicant obtains claims data that will be combined with the Medicare data. The attestation should include geographic area and types of providers and suppliers included in the data shared with the prospective QE.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Element 2B: Accurately combine Medicare claims data with claims data from other payer sources
Assessments:	Self -assessments:
1. Applicant accurately combines Medicare claims data with claims data from at least one other payer source.	Yes No
2. Applicant demonstrates experience, generally 3 or more years, accurately combining claims data from different payer sources.	Yes No
Explanation of Self-assessments:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
1. Documented process for combining claims data from multiple payers for the purposes of performance measurement. At a minimum, this must include the applicant’s method for matching provider and supplier identifiers across different claims data sources.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
2. Document(s) showing 3 years of experience aggregating claims data to produce at least two performance measures.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Standard 3: Data Security

Intent: A prospective QE must provide evidence of rigorous data privacy and security policies including enforcement mechanisms.

Element 3A (Administrative): Show ability to comply with Federal data security and privacy requirements, and document a process to follow those protocols
Assessment:	Self -assessment:
Applicant has established systems and protocols to address the following security elements (as detailed in FIPS 200): Audit and Accountability Certification, Accreditation, and Security Assessments Incident Response, including notifying CMS and beneficiaries of inappropriate data access, violations of applicable Federal and state privacy and security laws and regulations for the preceding 10-year period (or, if the applicant has not been in existence for 10 years, the length of time the applicant has been an organization), and any corrective actions taken to address the issues Planning Risk Assessment Compliance with applicable state laws regarding privacy and security	Yes No
Explanation of Self-assessment:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
Current NIST Certification and Accreditation for compliance with FIPS 200 and SP 800-53 at the moderate impact level. If the applicant has not undergone this Certification and Accreditation process, it must produce documentation of the systems and protocols that meet this same threshold with respect to the security factors listed in Element 3A, which are further described below. If these systems and protocols do not meet the standards of FIPS 200 and SP 800-53 or have not yet been fully implemented, the applicant may be granted an opportunity to submit an agreed-upon plan of action and milestones (POA&M) and subsequently must demonstrate appropriate improvements to meet compliance. Audit and Accountability: Applicant must: (i) create, protect, and retain information system audit records to the extent needed to enable the monitoring, analysis, investigation, and reporting of unlawful, unauthorized, or inappropriate information system activity; and (ii) ensure that the actions of individual information system users may be uniquely traced to those users so they can be held accountable for their actions. Certification, Accreditation, and Security Assessments: Applicant must (i) periodically assess the security controls in organizational information systems to determine if the controls are effective in their application; (ii) develop and implement plans of action designed to correct deficiencies and reduce or eliminate vulnerabilities in organizational information systems; (iii) authorize the operation of organizational information systems and any associated information system connections; and (iv) monitor information system security controls on an ongoing basis to ensure the continued effectiveness of the controls. Incident Response: Applicant must (i) establish an operational incident handling capability for organizational information systems that includes adequate preparation, detection, analysis, containment, recovery, and user response activities; and (ii) track, document, and report incidents to organizational officials and/or authorities. Planning: Applicant must develop, document, periodically update, and implement security plans for organizational information systems that describe the security controls in place or planned for the information systems and the rules of behavior for individuals accessing the information systems. Risk Assessment: Applicant must periodically assess the risk to organizational operations (including mission, functions, image, or reputation), organizational assets, and individuals, resulting from the operation of organizational information systems and the associated processing, storage, or transmission of organizational information. Compliance with applicable state laws regarding privacy and security: Applicants, regardless of Certification and Accreditation status, must document compliance with applicable state laws regarding privacy and security.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
All applicants, regardless of Certification and Accreditation status, must document all breaches of data security or privacy within the past 10 years (or the lifetime of the organization if that is less than 10 years).
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
3. All applicants, regardless of Certification and Accreditation status, must document the protocols and systems that will be implemented for transferring information to providers and suppliers as part of the requests for corrections/appeals process.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Element 3B (Technical): Identify system users and prequalification process for access to data
Assessment:	Self -assessment:
Applicant has established systems and protocols to address the following security elements (as detailed in FIPS 200): Access Control Awareness and Training Configuration Management Identification and Authentication Personnel Security	Yes No
Explanation of Self-assessment:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
Current NIST Certification and Accreditation for compliance with FIPS 200 and SP 800-53 at the moderate impact level. If the applicant has not undergone this Certification and Accreditation process, it must produce documentation of the systems and protocols in place with respect to the security factors listed in Element 3B, and further described below. If these systems and protocols do not meet the standards of FIPS 200 and SP 800-53 or have not yet been fully implemented, the applicant may be granted an opportunity to submit an agreed-upon plan of action and milestones (POA&M) and subsequently demonstrate appropriate improvements to meet compliance. Access Control: Applicant must limit information system access to authorized users, processes acting on behalf of authorized users, or devices (including other information systems) and to the types of transactions and functions that authorized users are permitted to exercise. Awareness and Training: Applicant must: (i) ensure that managers and users of organizational information systems are made aware of the security risks associated with their activities and of the applicable laws, Executive Orders, directives, policies, standards, instructions, regulations, or procedures related to the security of organizational information systems; and (ii) ensure that organizational personnel are adequately trained to carry out their assigned information security-related duties and responsibilities. Configuration Management: Applicant must: (i) establish and maintain baseline configurations and inventories of organizational information systems (including hardware, software, firmware, and documentation) throughout the respective system development life cycles; and (ii) establish and enforce security configuration settings for information technology products employed in organizational information systems. Identification and Authentication: Applicant must identify information system users, processes acting on behalf of users, or devices and authenticate (or verify) the identities of those users, processes, or devices, as a prerequisite to allowing access to organizational information systems. Personnel Security: Applicant must: (i) ensure that individuals occupying positions of responsibility within organizations (including third-party service providers of services) are trustworthy and meet established security criteria for those positions; (ii) ensure that organizational information and information systems are protected during and after personnel actions such as terminations and transfers; and (iii) employ formal sanctions for personnel failing to comply with organizational security policies and procedures.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Element 3C (Physical): Identify processes and systems in place to protect the IT physical infrastructure
Assessment:	Self -assessment:
Applicant has established systems and protocols to address the following security elements (as detailed in FIPS 200): Contingency Planning Maintenance Media Protection Physical and Environmental Protection System and Services Acquisition System and Communications Protection System and Information Integrity	Yes No
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
Current NIST Certification and Accreditation for compliance with FIPS 200 and SP 800-53 at the moderate impact level. If the applicant has not undergone this Certification and Accreditation process, it must produce documentation of the systems and protocols in place with respect to the security factors listed in Element 3C, and described further below. If these systems and protocols do not meet the standards of FIPS 200 and SP 800-53 or have not yet been fully implemented, the applicant may be granted an opportunity to submit an agreed-upon plan of action and milestones (POA&M) and subsequently demonstrate appropriate improvements to meet compliance. Contingency Planning: Applicant must establish, maintain, and effectively implement plans for emergency response, backup operations, and post-disaster recovery for organizational information systems to ensure the availability of critical information resources and continuity of operations in emergency situations. Maintenance: Applicant must: (i) perform periodic and timely maintenance on organizational information systems; and (ii) provide effective controls on the tools, techniques, mechanisms, and personnel used to conduct information system maintenance. Media Protection: Applicant must: (i) protect information system media, both paper and digital; (ii) limit access to information on information system media to authorized users; and (iii) sanitize or destroy information system media before disposal or release for reuse. Physical and Environmental Protection: Applicant must: (i) limit physical access to information systems, equipment, and the respective operating environments to authorized individuals; (ii) protect the physical plant and support infrastructure for information systems; (iii) provide supporting utilities for information systems; (iv) protect information systems against environmental hazards; and (v) provide environmental controls in facilities containing information systems. System and Services Acquisition: Applicant must: (i) allocate sufficient resources to adequately protect organizational information systems; (ii) employ system development life cycle processes that incorporate information security considerations; (iii) employ software usage and installation restrictions; and (iv) ensure that third-party providers employ adequate security measures to protect information, applications, and/or services outsourced from the organization. System and Communications Protection: Applicant must: (i) monitor, control, and protect organizational communications (i.e., information transmitted or received by organizational information systems) at the external boundaries and key internal boundaries of the information systems; and (ii) employ architectural designs, software development techniques, and systems engineering principles that promote effective information security within organizational information systems. System and Information Integrity: Applicant must: (i) identify, report, and correct information and information system flaws in a timely manner; (ii) provide protection from malicious code at locations within organizational information systems; and (iii) monitor information system security alerts and advisories and take actions in response.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Standard 4: Methodology for measurement and Attribution

Intent: A prospective QE must provide evidence of its ability to accurately calculate quality and efficiency, effectiveness, or resource use measures from claims data for measures it intends to calculate with Medicare data.

Element 4A: Follow measure specifications
Assessment:	Self -assessment:
Applicant uses measure specifications accurately for selected measures, including numerator and denominator inclusions and exclusions, measured time periods, and specified data sources.	Yes No
Explanation of Self-assessment:
Evidence:
For the measures listed in Elements 5A and 5B, the applicant must supply the measure specifications through a hyperlink to the original specification, a URL, or a copy of the specifications.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Element 4B: Use a defined and transparent method for attribution of patients and episodes
Assessments:	Self -assessments:
1. Applicant identifies an appropriate method to attribute a particular patient's services or episode to specific providers and suppliers.	Yes No
2. Applicant demonstrates experience, generally 3 or more years, accurately attributing patient's services or episode to specific providers and suppliers.	Yes No
Explanation of Self-assessments:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
Methodology paper or document defining how the applicant attributes patient services or episodes to specific providers or suppliers. If the attribution methods are different for different types of providers and suppliers (or measures), the applicant describes each methodology.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

2. Methodology paper or document describing attribution approaches the applicant has defined and executed over the past 3 years. Note that if the attribution methodology has changed over the past 3 years, the applicant must provide a rationale for the change.

Supporting Documentation:

Document 1

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 2

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 3

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Element 4C: Set and follow requirements to establish statistical validity of measure results for quality measures
Assessments:	Self -assessments:
1. For reporting quality measures using Medicare data, applicant uses only measures with at least 30 observations, or the calculated confidence interval is at least 90%, or the measure reliability is at least 0.70.	Yes No
2. Applicant demonstrates experience, generally 3 or more years, producing measures with statistical validity.	Yes No
Explanation of Self-assessments:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
Methodology paper or document stating the applicant's minimum requirements for reporting a measure that incorporates any of the received Medicare data. This includes one of the following: minimum sample size (or denominator size) requirements, minimum calculated confidence interval, or minimum reliability score requirements.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
For each measure for which the applicant intends to incorporate Medicare data, the applicant must submit one of the following: the anticipated sample size, the reliability score, or the confidence interval that will be used in reporting. Evidence supporting these statements must be submitted.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
Document(s) showing the applicant’s requirements for establishing statistical validity, together with examples of how the applicant has applied them over the past 3 years for at least two quality measures for which it intends to incorporate Medicare data. If any of the selected quality measures require the application of distinct or different statistical thresholds, then these must also be submitted.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Element 4D: Set and follow requirements to establish statistical validity of measure results for efficiency, effectiveness, and resource use measures
Assessments:	Self -assessments:
For selected efficiency, effectiveness, and resource use measures using Medicare data, applicant uses only measures for which reliability and validity is demonstrated.	Yes No N/A
For selected efficiency, effectiveness, and resource use measures using Medicare data that specify the use of a standardized payment or pricing approach, the specified standardized payment methodology is used.	Yes No N/A
Applicant demonstrates experience, generally 3 or more years, producing measures with statistical validity.	Yes No N/A
Applicants are only required to submit evidence for Element 4D if they select efficiency, effectiveness, or resource use measures to evaluate providers or suppliers.
Explanation of Self-assessments:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
Methodology paper that states the applicant's minimum requirements for reporting a measure with combined data. This includes the minimum calculated confidence interval or the reliability score.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
For each measure for which the QE intends to incorporate Medicare data, the applicant must submit one of the following: the anticipated sample size, the reliability score, or the confidence interval that will be used in reporting. Evidence supporting these statements must be submitted.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
Document(s) showing the applicant’s requirements for establishing statistical validity, together with examples of how the applicant has applied them over the past 3 years for each selected type of measure (efficiency, effectiveness, and resource use) for which it intends to incorporate Medicare data. If any of the selected measures require the application of distinct or different statistical thresholds, then these must also be submitted.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

4. Description of standard payment methodology for applicable measures.

Supporting Documentation:

Document 1

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 2

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 3

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Element 4E: Use appropriate methods to employ risk adjustment
Assessments:	Self -assessments:
1. Applicant provides a rationale for using, or not using, a risk adjustment method for each selected measure. Furthermore, the applicant provides a description of the risk adjustment method for each applicable measure.	Yes No N/A
2. Applicant demonstrates experience, generally 3 or more years, applying risk adjustment if any of the selected measures require a risk adjustment approach.	Yes No N/A
Applicants are only required to submit evidence for Element 4E if they select a measure(s) that specifies a risk adjustment method.
Explanation of Self-assessments:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
1. Methodology paper indicating for each measure for which the applicant intends to use Medicare data: How the applicant has determined whether risk adjustment is necessary The explicit methodology to be used for risk adjustment, including any case-mix or severity adjustment A justification if the applicant determines that risk adjustment is not necessary
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
Document(s) showing consideration of risk adjustment, use of risk adjustment methodologies, and/or justification for not using risk adjustment over the past 3 years.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Element 4F: Use appropriate methods to handle outliers
Assessments:	Self -assessments:
1. Applicant describes its outlier method (i.e., how to identify and account for outliers) for each selected measure as applicable.	Yes No
2. Applicant demonstrates experience, generally 3 or more years, applying relevant outlier methods, as applicable.	Yes No
Explanation of Self-assessments:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
1. Methodology paper indicating for each measure with which the applicant intends to incorporate Medicare data: Rationale to use, or not use, an outlier method Detailed description of outlier method; specifically, how to identify outliers (e.g., more than 3 standard deviations from the mean) and how to account for them (e.g., truncation or removal of outlier).
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
Document(s) showing identification of outliers, use of outlier methods, or justification for not using outlier methods over the past 3 years, for each type of measure.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Element 4G: Use comparison groups when evaluating providers or suppliers compared to each other
Assessments:	Self -assessments:
1. Applicant defines comparison groups it intends to use to report results for each selected measure.	Yes No
2. Applicant demonstrates experience, generally 3 or more years, selecting relevant comparison groups (i.e., peer groups) for selected measures.	Yes No
Explanation of Self-assessments:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
1. Description of the comparison or peer groups used to evaluate performance for each measure selected. Peer group identification includes each type of provider and supplier to be reported on, including: How the peer group was identified (external data source, provider-reported specialty, Tax ID number) Defined algorithms to identify relevant peer groups for measurement Geographic parameters to correctly compare providers to their peers
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
Document(s) showing the peer groups to which providers and suppliers have been assigned, and how peer groups have been defined, during the past 3 years.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Element 4H: Use benchmarks when evaluating providers
Assessments:	Self -assessments:
1. Applicant defines benchmarks it intends to use to report results for each selected measure.	Yes No
2. Applicant demonstrates experience, generally 3 or more years, comparing measure results with benchmarks.	Yes No
Explanation of Self-assessments:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
1. Description of the benchmark selection process and any performance standard that is used. The benchmark selection process includes: How the benchmark is identified or estimated (external data source, current data set) Type of benchmark (90th percentile, national average, regional average, Geographic parameters to correctly identify the benchmark if relevant (provided region assignment uses regional benchmarks)
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

2. Document(s) showing the comparison of performance results of providers and suppliers with benchmarks during the past 3 years.

Supporting Documentation:

Document 1

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 2

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 3

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Standard 5: Measure Selection

Intent: A prospective QE must provide documentation for each selected standard or alternative measure used in public reporting to demonstrate its validity, reliability, responsiveness to consumer preferences, and applicability.

Element 5A: Use standard measures
Assessment:	Self -assessment:
Applicant selects standard measures for which it intends to incorporate Medicare data.	Yes No
Explanation of Self-assessment:
Evidence:
List of selected measures for performance reporting. A description of each measure including: Name of measure Name of measure steward/owner Measure description Type of provider or supplier to which the applicant will apply the measure Hyperlink, URL, or copy of the measure specification Rationale for selecting the measure, including the relationship of the measure to existing measurement efforts and the relevance to the proposed population in the proposed geographic area
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Element 5B: Use approved alternative measures
Assessments:	Self -assessments:
1. Applicant proposes alternative measure for which it intends to incorporate Medicare data. Composite measures are considered alternative measures, even if they composite or combine standard measures, unless the standard measure itself is a composite.	Yes No N/A
2. Applicant demonstrates the measure is more valid, reliable, responsive to consumer preferences, cost-effective, or relevant to dimensions of quality and resource use not addressed by a standard measure, through consultation and agreement with stakeholders in applicant’s community or through the notice and comment rulemaking process.	Yes No N/A
Applicants are only required to submit evidence for Element 5B if they select an alternative measure to evaluate providers or suppliers.
Explanation of Self-assessments:
Evidence:
List of proposed selected alternative measures. A description of each measure including: Name of measure Name of measure steward/owner Measure description Type of provider or supplier to which the applicant will apply the measure Hyperlink, URL, or copy of the measure specification Evidence that the measure is more valid, reliable, responsive to consumer preferences, cost-effective, or relevant to dimensions of quality and resource use not addressed by a standard measure Rationale for selecting the measure, including the relationship of the measure to existing measurement efforts and the relevance to the proposed population in the proposed geographic area Process to monitor and evaluate if new scientific evidence is released or a related standard measure is endorsed. If new evidence or a standard measure is available, the QE must notify CMS (QECP team) and submit all the new evidence. The QE must start using the new standard measure within 6 months or the QE can request, with supporting scientific documentation, approval to continue using the alternative measure.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
Documentation of consultation and agreement with stakeholders in the applicant’s community, together with a description of the discussion about the proposed alternative measure, including a summary of all pertinent arguments supporting and opposing the measure or documentation of notice and comment rulemaking process approval.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Standard 6: VERIFICATION PROCESS

Intent: A prospective QE must provide evidence of a continuous process to correct measurement errors and assess measure reliability.

Element 6A: Systematically evaluate accuracy of the measurement process, and correct errors
Assessment:	Self -assessment:
Applicant demonstrates experience, generally 3 or more years, defining and verifying its measurement and reporting processes, including the correction of errors and updating of performance reports.	Yes No
Explanation of Self-assessment:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
Internal verification, audit process, or software used to evaluate the accuracy of calculating performance measures from claims data.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

2. Name, credentials, and title of staff responsible for verifying the measurement process.

Supporting Documentation:

Document 1

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 2

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 3

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

3. Process for correcting errors.

Supporting Documentation:

Document 1

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 2

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 3

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

4. Process for updating reports to providers, suppliers, and consumers.

Supporting Documentation:

Document 1

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 2

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 3

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

5. Sample report generated by the validation process.

Supporting Documentation:

Document 1

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 2

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 3

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

6. If using an external vendor, documentation of agreement and/or purchase order of the software and/or systems vendor utilized in the applicant’s validation process.

Supporting Documentation:

Document 1

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 2

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 3

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

7. Document(s) showing applicant has 3 years of experience in evaluating the accuracy of the measurement process and correcting errors covering all relevant areas.

Supporting Documentation:

Document 1

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 2

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 3

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Standard 7: reporting of performance Information

Intent: A prospective QE must demonstrate substantial experience and expertise in the design and dissemination of performance reports, as well as the capacity and commitment to continuously improve the reporting process.

Element 7A: Design reporting for providers, suppliers, and the public
Assessments:	Self -assessments:
Applicant designs public reporting to be produced using Medicare data, including understandable descriptions of measures used.	Yes No
Applicant plans dissemination of information to users at least annually.	Yes No
Explanation of Self-assessments:
Evidence:
List of types of providers and suppliers in each geographic area to be covered by performance reporting.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
Performance rating approach(es), including the measure results and statistical methods used to estimate a rating.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
Prototype or mock-up of reports, including all items of information for the providers and suppliers as they will be displayed, including level of reporting, as well as any rating approaches (such as number of stars) to display performance. The prototypes must clearly explain the performance results or ratings. All prototypes must be submitted if they are different (e.g., the provider or supplier prototype and the public report prototype). Prototypes must further demonstrate: An indication, for each item reported, whether or not it is to be calculated in any part with Medicare data An understandable description of the measures used to evaluate the performance of providers and suppliers so that consumers, providers and suppliers, health plans, researchers, and other stakeholders can assess performance reports Intended reporting at the provider or supplier level, or at a higher, more aggregated level (consistent with measure specifications) Intended display of measures in dispute (per provider)
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________
Dissemination plans to inform all intended audiences of the existence of the performance reports, including how to locate them.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Element 7B: Improve reporting
Assessment:	Self -assessment:
Applicant demonstrates experience, generally 3 or more years, designing and continuously improving public reporting on health care quality, efficiency, effectiveness, or resource use.	Yes No
Explanation of Self-assessment:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
Document(s) showing results of previous evaluation of reporting for the past 3 years, such as testing with users and use of evaluations to improve reporting.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Standard 8: Requests for Corrections/Appeals

Intent: A prospective QE must provide evidence of implementing and maintaining an acceptable process for providers and suppliers identified in a report to review the report prior to publication and providing a timely response to provider and supplier inquiries regarding requests for data, error correction, and appeals.

Element 8A: Use corrections process
Assessment:	Self -assessment:
Applicant has established a process to allow providers and suppliers to view reports confidentially, request data, and ask for correction of errors before the reports are made public.	Yes No
Explanation of Self-assessment:
Evidence: Evidence of experience submitted by the applicant may be the demonstrated experience of the applicant, of the applicant’s contractor, or, if the applicant is a collaborative, of any member organization of the collaborative.
Process by which the applicant will share relevant information about anticipated public reporting on a provider or a supplier with that provider or supplier at least 60 business days prior to publicly reporting results. Applicant demonstrates experience, generally 3 or more years, including sharing: Selected measures on which the provider or supplier is being measured Rationale for use Measurement methodology Data specifications and limitations Measure results for the provider or supplier Anticipated date for publishing reports for the public Description of the ongoing process by which providers or suppliers may Request additional information or data Request corrections or changes prior to public reporting

Supporting Documentation:

Document 1

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 2

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Document 3

Document Name: ___________________________________________________________

Document Relevance: ________________________________________________________

Relevant Pages: _____________________________________________________________

Element 8B: Use secure transmission of beneficiary data
Assessment:	Self -assessment:
Applicant has established a process that applies privacy and security protections to the release of beneficiary identifiers and claims data to providers or suppliers for the purposes of the requests for corrections/appeals process.	Yes No
Explanation of Self-assessment:
Evidence:
Description of process ensuring that only the minimum necessary beneficiary identifiers and claims data will be disclosed in the event of a request by a provider or a supplier, including the method for secure transmission.
Supporting Documentation:
Document 1 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 2 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________ Document 3 Document Name: ___________________________________________________________ Document Relevance: ________________________________________________________ Relevant Pages: _____________________________________________________________

Section 5: Attestation

Instructions: Prior to an application being submitted as final, the contents of the application must be accompanied with a completed attestation from an individual at the entity authorized to attest to its accuracy and completion.

To the best of my knowledge and belief, all data in this application are true and correct, the document has been duly authorized by the governing body of the applicant, and the applicant will comply with the terms and conditions of the award and applicable Federal requirements awarded.

Authorized Representative’s Name (printed) _________________________________________

Authorized Representative’s Title (printed) __________________________________________

Signature_____________________________________________ Date ____________________

Phone _______________________________________ Fax _____________________________

Section 6: Additional Supporting Documentation

Instructions: Please describe all additional supporting documentation submitted in conjunction with this application that is not listed in Section 4.

1. Standard: _____________

Element: _____________

Document Name: _______________________________________________________

Document Relevance: ____________________________________________________

Relevant Pages: _________________________________________________________

2. Standard: _____________

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Document Relevance: ____________________________________________________

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8. Standard: _____________

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11. Standard: _____________

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15. Standard: _____________

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Department of Health & Human Services B-1 OMB No. 0938-1144

Centers for Medicare & Medicaid Services Exp. xx/xx/xxxx